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Chaplaincy and clinical ethics: a common set of questions.

The ethical imperative for quality improvement in health care requires that all health care personnel engage in attentive observation, reflection, innovative thinking, and action. A core QI question for everyone working in a clinical setting is this: How can the delivery and service systems I participate in be improved to enhance and improve quality of care for patients and families? Chaplains, chaplaincy programs, clinical ethics consultants, and ethics committees all share this commitment. A challenge for both chaplains and ethics consultants is to articulate their unique roles, purposes, goals, and objectives so that they can establish adequate educational and training standards and programs, measure what they are doing against what they should be doing, and initiate, participate in, and maintain QI initiatives.

Both chaplains and ethics consultants generally claim to have distinctive roles, activities, knowledge, skills, and competencies. Nevertheless, similarities in their activities suggest that advantages may result from partnering as each group searches for its place in the health care system and for ways to best introduce QI interventions. Chaplains and clinical ethicists together could identify, recommend, and promote methods useful to both groups in the clinical context.

Chaplains and ethics consultants engage in many similar activities. For example, both meet with patients and their families one-on-one and during patient care conferences; both serve on interdisciplinary teams and participate in multidisciplinary clinical rounds; both document their interventions in patients' medical records; both provide services to and routinely interact with clinical staff and other employees; both participate as members of ethics committees and may lead ethics committees; and both participate as members of other organizational groups, such as institutional review boards and conflict of interest committees. In some hospitals and other health care settings, a chaplain may be the ethics consultant (where the individual consultant model is used) or may be included routinely as a member of ethics consultation teams. Both chaplains and clinical ethicists can serve as patient advocates, assist with advance care planning, facilitate communication and reduce conflicts among various stakeholders, and refer patients, families, and staff to other organizational resources after identifying their needs.

As a result, both chaplains and clinical ethicists need similar skill sets, knowledge areas, and character traits. They should be attentive listeners who are able to communicate interest, respect, support, and empathy. They must be adept at recognizing verbal and nonverbal cues, especially during difficult conversations, and they must be able to assertively articulate their own assessments, insights, and recommendations. Both groups must understand not only the health care systems and clinical contexts in which they work (including relevant institutional policies, procedures, and practices), but also any special beliefs and perspectives of patients, families, and staff. Character traits both groups share include compassion, integrity, humility, honesty, courage, and self-knowledge. Further, the activities and services of both chaplains and clinical ethicists usually do not generate income, and so both groups must demonstrate their "value-added" impact in ways other than by just adding up billable hours.

Neither chaplains nor clinical ethicists can claim a monopoly on expertise in their principle areas of service and focus--spirituality and ethical decision-making, respectively. Other members of the health care team and staff may have significant expertise in these areas as well. Further, in addition to certified chaplains, some health care organizations use chaplain volunteers, some with less--but some with more--knowledge, skills, and experience than their certified colleagues. Similarly, in addition to (or instead of ) paid clinical ethicists, many organizations have volunteer ethics committee consultants, some with less--but some with more--knowledge, skills, and experience than their paid counterparts.

Both chaplains and clinical ethicists, then, struggle with a common set of questions: What are our unique roles and contributions? What are the core elements of our work that only we can bring to the health care encounter? What character traits enable someone to become a contributing practitioner of a "professionalizing profession"? What measures of effectiveness should we use to evaluate our work and inform quality improvement? Should clinical ethics permit multiple certifying bodies (as currently exist for chaplains) or one centralized certifying organization? Should clinical ethics follow chaplaincy in establishing standards for training programs and competencies for trainees?

At this stage in the evolution of chaplaincy and clinical ethics, each profession has some clear accomplishments and foundational elements upon which to build, but there are more for chaplaincy than for clinical ethics. Despite some diversity among chaplaincy interest groups, chaplains, pastoral counselors, pastoral educators, and students regulate themselves through a common professional code of ethics that offers basic values, standards of practice, and a mechanism for accountability. Accreditation is available for clinical pastoral education (CPE) programs that adhere to requirements for the admission of trainees and to explicit standards related to CPE's specialized teaching, training, and supervision. Programs for training future CPE supervisors also exist. The U.S. Department of Education and the Centers for Medicare and Medicaid Services provide a "stamp of approval" for these chaplaincy and supervisory training programs by reimbursing for the trainees' supervised hours of pastoral care. Successful chaplain trainees completing the required number of units and hours of CPE training can be "certified" (not licensed) as chaplains. The Spiritual Care Collaborative, representing the various chaplaincy certifying bodies, has identified a common set of competencies and expertise for certification. Certification affirms that core competencies have been achieved, and it provides credentialing for providing pastoral care services in a clinical setting. Continuing education credits are required annually to maintain certifications.

Clinical ethicists lag behind. A set of core competencies limited to ethics consultation was developed by a national task force made up of twenty-one scholars from medicine, nursing, law, philosophy, religious studies, regulatory agencies, and the College of Chaplains (the precursor to the current Association of Professional Chaplains). The core competencies were set forth as voluntary guidelines, and the task force members unanimously concluded, when their report was published in 1998, "that certification of individuals or groups to do ethics consultation is, at best, premature." (1) Although various academic and training programs in bioethics and clinical ethics have emerged and some grant academic degrees, no clinically based training or fellowship programs are accredited or provide a basis for certification because no accrediting or certifying body exists. Based on the identified core competencies for ethics consultation, the American Society for Bioethics and Humanities will soon publish a recommended and voluntary "education guide" for improving proficiencies in the core competencies for ethics consultation. The ASBH's leadership and members have debated whether to develop a code of ethics for the organization, or at least for clinical ethicists, and a task force has studied the issue. To date, however, there is a lack of consensus about moving forward with such a document. Finally, absent certification (or licensure), continuing education units are not required for clinical ethicists.

Despite their respective progress toward emerging identities, gaps remain for both chaplains and clinical ethicists, especially in the areas of evaluation and, correspondingly, quality improvement. In an evidence-based environment such as health care, a clear need exists for concrete methods and mechanisms to evaluate effectiveness and impact based on standards of performance. But to date, the efforts of both chaplaincy and clinical ethics have been limited. Simply counting the number of pastoral care visits or ethics consultations addresses quantity but not quality. Patient and family satisfaction scores can be deceiving, and they do not take into account the nuances and subtleties of chaplains' and clinical ethicists' proper roles. Indeed, chaplains' and clinical ethicists' work may not always contribute to "satisfied clients." Some who are served by them--for instance, a patient who orders a chaplain out of a hospital room because the chaplain is a woman, or a family member who strongly disagrees with an ethics consultant's recommendation to disclose medical prognosis to an adult patient with decision-making capacity--may express high dissatisfaction with the respective services rendered. And even if a patient is satisfied, a hospital may be unable to measure that satisfaction according to the same scale it uses to gauge success in more objective areas. For instance, the work both chaplains and clinical ethicists do advocating for patients will not necessarily decrease a patient's length of stay or help to more efficiently utilize hospital resources.

Although neither chaplaincy nor clinical ethics has been able to fully identify or develop its role in modern health care, both make their own unique contributions to the care of patients, families, and staff. The many commonalities of both "professionalizing professions" warrants their increased collaboration to address the similar challenges that each faces.

(1.) American Society for Bioethics and Humanities, Core Competencies for Health Care Ethics Consultation (Glenview, Ill.: 1998), 31.
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Title Annotation:Essays
Author:Smith, Martin L.
Publication:The Hastings Center Report
Date:Nov 1, 2008
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